Infant Mortality Patterns in Åland, Finland

This is the published version. Copyright 1983 Wayne State University Press.Infant mortality in Åland, Finland, from 1751 to 1935 is examined. The 18th and early 19th century rates in Åland were more characteristic of Eastern European populations than Western Europe or England. A steady decline in the mortality rates and a reduction in the year-to-year variation began about 1810. This decline is linked to medical innovations, decreases in household and family size, and socioeconomic changes. Stillbirth ratios appear to be relatively high and stable from 1751 to 1935 (ranging from 17 to 37/1000). Regional variation in infant mortality rates in the Åland archipelago does not appear to be shaped by either geographic location of the parishes or population density. Data are provided for causes of death during the neonatal and postneonatal periods. A time series analysis demonstrated that high birth rates tend to co-occur with periods of high infant mortality. Factors that may have influenced the infant mortality rates include household size and complexity, twinning rates, and breast feeding patterns

Outcomes of Adult Patients with Small Body Size Supported with a Continuous-Flow Left Ventricular Assist Device

There is insufficient data on patients with small body size to determine if this should be considered a risk factor for continuous-flow left ventricular assist device (CF-LVAD) support. We sought to evaluate survival outcomes, adverse events, and functional status of CF-LVAD patients with body surface area (BSA) <1.5 m2 in a large national registry. Adults with BSA < 1.5 m2 (n = 128) implanted with a HeartMate II (HMII)-LVAD from the Interagency Registry for Mechanically Assisted Circulatory Support registry from April 2008 to December 2012 formed this cohort. Outcomes were compared with HMII bridge to transplant (BTT) and destination therapy (DT) post approval studies. The majority of patients were female (n = 106, 83%). A total of 64% (n = 82) were implanted for BTT and 36% (n = 46) for DT. The median BSA (range) was 1.44 (1.19–1.49) and 1.45 (1.25–1.49) m2 for BTT and DT, respectively. Overall survival 1 year post implant was 81% ± 5% for BTT and 84% ± 6% for DT. The most common adverse events for BTT and DT patients were bleeding (0.91, 0.88 events/patient year) and driveline infection (16%, 0.28 events/patient year). Six months post implantation, 87% of BTT and 77% of DT patients were New York Heart Association functional class I or II. Post implant survival, functional status improvement, and adverse event profile for adult BTT and DT HMII patients with BSA < 1.5 m2 are favorable and comparable with outcomes published in the overall patient population

Chronotropic incompetence predicts mortality in severe obstructive pulmonary disease

We evaluated the prevalence of chronotropic incompetence (CI), a marker of autonomic dysfunction, and its prognostic value in patients with chronic obstructive pulmonary disease (COPD). We performed a retrospective analysis of 449 patients with severe COPD who underwent a cardiopulmonary exercise test, after excluding patients with lung volume reduction surgery, left ventricular dysfunction and those not in sinus rhythm. CI was defined as percent predicted heart rate reserve (%HRR). Events were defined as death or lung transplant during a median follow-up of 68 months. Median age was 61 years; median percent predicted forced expiratory volume in one second (%FEV1) of 25% and median %HRR of 33%. The hazard ratio for an event in the lowest quartile of %HRR, taking the highest quartile as reference, was of 3.2 (95% confidence interval: 2.1-4.8; p < 0.001). In a multivariate regression model, %HRR was an independent predictor of events. In conclusion, Cl was an independent and powerful outcome predictor in patients with severe COPD. (C) 2013 Elsevier B.V. All rights reserved

Hypertension: an unstudied potential risk factor for adverse outcomes during continuous flow ventricular assist device support

In end-stage heart failure, left ventricular assist devices (LVADs) represent an exciting new frontier in which post-device implantation survival approaches that of heart transplant. However, expansion of this technology is still limited by complications that impact morbidity and mortality. Thus, it is essential to identify and optimize modifiable predictors of poor outcomes. One such predictor may be hypertension (HTN). Not only may chronic HTN as a traditional cardiovascular risk factor be present during long-term LVAD support, but HTN may also contribute to device malfunction or device-associated complications. Although current guidelines identify blood pressure (BP) control as important to outpatient continuous flow (CF) LVAD management, there is no evidence base to support these guidelines. Indeed, our comprehensive literature search did not identify any studies that evaluated post-device implantation HTN as a potential predictor of adverse CF-LVAD outcomes. HTN among CF-LVAD patients is likely a relatively unstudied factor because of difficulties using standard noninvasive techniques to measure BP in the setting of reduced pulsatile flow. Fortunately, recent research has elucidated the meaning of Doppler BP measurements and validated a slow-cuff deflation system for BP measurements in the setting of CF-LVAD support. Therefore, CF-LVAD researchers and clinicians may (1) consider potential mechanisms relating HTN to poor outcomes, (2) realize that HTN management is a stated goal despite scarce evidence, and (3) utilize the new reliable and valid methods for outpatient BP measurement that make research and management possible. It is critical and now feasible that research on HTN in the CF-LVAD patient population move forward

Effect of acute \u3b2-blocker withholding on ventilatory efficiency in patients with advanced chronic heart failure

BACKGROUND: This is the first study to examine the effect of acute (24-hour) beta-blocker withholding on ventilatory efficiency in patients with advanced chronic heart failure (CHF) during maximal incremental treadmill cardiopulmonary exercise test. METHODS AND RESULTS: Seventeen CHF patients were studied either 3 hours after administration of beta-blocker (BB(ON)) or 27 hours after the last beta-blocker ingestion (BB(OFF)). The ventilatory efficiency was measured via the slope of the linear relationship between ventilation (V'(E)) and carbon dioxide production (V'CO2) (ie, V'(E)/V'CO2 slope). Measurements were also made at rest, anaerobic threshold (AT), maximal end-tidal pressure for carbon dioxide (P(ET)CO2max), respiratory compensation point (RC), and peak exercise. Compared with BB(ON), the V'(E)/V'CO2 slope was significantly increased during BB(OFF) (30.8 +/- 7.4 vs. 29.1 +/- 5.4, P = .04). At peak exercise, oxygen uptake (V'O2, 16.0 +/- 2.7 vs. 15.6 +/- 2.8 mL x kg x min) and V'CO2 (1458 +/- 459 vs. 1414 +/- 429 mL/min) were not different between the 2 conditions, whereas V'(E) was higher during BB(OFF) (49.5 +/- 10.7 vs. 46.1 +/- 9.6 L/min, P = .04). No differences were noted at AT and RC in V'O2, V'CO2, V'(E), V'(E)/V'O2, and V'(E)/V'CO2 ratios during the 2 conditions. At P(ET)CO2max, used to noninvasively estimate the CO2 set point, V'(E) was higher (33.9 +/- 7.6 vs. 31.7 +/- 7.3 L/min, P = .002) and P(ET)CO2 was lower (37.4 +/- 4.8 vs. 38.5 +/- 4.0 mm Hg, P = .03), whereas V'CO2 was unchanged (1079 +/- 340 vs. 1050 +/- 322 mL/min) during BB(OFF). CONCLUSION: Acute beta-blocker withholding resulted in decreased ventilatory efficiency mostly from an increase of V'CO2-independent regulation of V'(E) and less likely from a change in ventilation/perfusion mismatchin

A history of heart failure is an independent risk factor for death in patients admitted with coronavirus 19 disease

Aims: The association between cardiovascular diseases, such as coronary artery disease and hypertension, and worse outcomes in COVID-19 patients has been previously demonstrated. However, the effect of a prior diagnosis of heart failure (HF) with reduced or preserved left ventricular ejection fraction on COVID-19 outcomes has not yet been established. Methods and Results: We retrospectively studied all adult patients with COVID-19 admitted to our institution from March 1st to 2nd May 2020. Patients were grouped based on the presence or absence of HF. We used competing events survival models to examine the association between HF and death, need for intubation, or need for dialysis during hospitalization. Of 4043 patients admitted with COVID-19, 335 patients (8.3%) had a prior diagnosis of HF. Patients with HF were older, had lower body mass index, and a significantly higher burden of co-morbidities compared to patients without HF, yet the two groups presented to the hospital with similar clinical severity and similar markers of systemic inflammation. Patients with HF had a higher cumulative in-hospital mortality compared to patients without HF (49.0% vs. 27.2%, p &lt; 0.001) that remained statistically significant (HR = 1.383, p = 0.001) after adjustment for age, body mass index, and comorbidities, as well as after propensity score matching (HR = 1.528, p = 0.001). Notably, no differences in mortality, need for mechanical ventilation, or renal replacement therapy were observed among HF patients with preserved or reduced ejection fraction. Conclusions: The presence of HF is a risk factor of death, substantially increasing in-hospital mortality in patients admitted with COVID-19

Effect of Intraduodenal Bile and Na-Taurodeoxycholate on Exocrine Pancreatic Secretion and on Plasma Levels of Secretin, Pancreatic Polypeptide, and Gastrin in Man

The effect of intraduodenally administered cattle bile (CB) and Na-taurodeoxycholate (TDC) on basal pancreatic secretion and plasma levels of secretin, pancreatic polypeptide (PP), and gastrin were investigated on two separate days in 10 fasting volunteers. Doses of 2-6 g CB and 20&600 mg TDC were given intraduodenally at 65-min intervals. Volume, bicarbonate, lipase, trypsin, amylase, and bilirubin were measured in 10-min fractions of duodenal juice, and GI peptides determined by radioimmunoassay. CB and TDC enhanced significantly and dose-dependently volume, bicarbonate and enzyme secretion, and plasma secretin and PP levels. In contrast, plasma gastrin showed only a marginal increase. We conclude that the hydrokinetic effect of intraduodenal CB and TDC is at least partially mediated by secretin. Gastrin could be ruled out as a mediator of the ecbolic effect, whereas other GI peptides, primarily CCK, and/or neural mechanisms must be considered possible mediators. Both pathways may also play a role in the PP release

Development of a Novel Echocardiography Ramp Test for Speed Optimization and Diagnosis of Device Thrombosis in Continuous-Flow Left Ventricular Assist Devices The Columbia Ramp Study

ObjectivesThis study sought to develop a novel approach to optimizing continuous-flow left ventricular assist device (CF-LVAD) function and diagnosing device malfunctions.BackgroundIn CF-LVAD patients, the dynamic interaction of device speed, left and right ventricular decompression, and valve function can be assessed during an echocardiography-monitored speed ramp test.MethodsWe devised a unique ramp test protocol to be routinely used at the time of discharge for speed optimization and/or if device malfunction was suspected. The patient's left ventricular end-diastolic dimension, frequency of aortic valve opening, valvular insufficiency, blood pressure, and CF-LVAD parameters were recorded in increments of 400 rpm from 8,000 rpm to 12,000 rpm. The results of the speed designations were plotted, and linear function slopes for left ventricular end-diastolic dimension, pulsatility index, and power were calculated.ResultsFifty-two ramp tests for 39 patients were prospectively collected and analyzed. Twenty-eight ramp tests were performed for speed optimization, and speed was changed in 17 (61%) with a mean absolute value adjustment of 424 ± 211 rpm. Seventeen patients had ramp tests performed for suspected device thrombosis, and 10 tests were suspicious for device thrombosis; these patients were then treated with intensified anticoagulation and/or device exchange/emergent transplantation. Device thrombosis was confirmed in 8 of 10 cases at the time of emergent device exchange or transplantation. All patients with device thrombosis, but none of the remaining patients had a left ventricular end-diastolic dimension slope >−0.16.ConclusionsRamp tests facilitate optimal speed changes and device malfunction detection and may be used to monitor the effects of therapeutic interventions and need for surgical intervention in CF-LVAD patients